What is your preferred pharmacologic agent for recurrent VT suppression in arrhythmogenic right ventricular cardiomyopathy?
In general, I like VT/PVC-focused beta-blockers which tend to be nadolol and propranolol (for example in CPVT, nadolol bested other BBs - Heart Rhythm 2016 Leren et al and propranolol over metoprolol in VT storm - JACC 2018 Chatzidou et al). According to the 2019 HRS expert consensus statement on arrhythmogenic cardiomyopathies (Towbin et al., PMID 31078652), it received an IIa reasonable indication.
Next up are amiodarone and sotalol as an IIb consider for refractory symptomatic ventricular arrhythmias. Smaller early studies suggested benefits with either of these (Marcus et al., PMID 19695454 for amio and Wichter et al., PMID 1617780 for sotalol). Amio obviously carries a higher side effect profile which might be limiting.
The guidelines also note flecainide with BB (but not sotalol or amio) as an IIb consider, particularly with preserved LV and RV function. I've found my ARVCs often have the RV dysfunction or dilation already so haven't used this strategy at all.
I've had the most experience with nadolol and sotalol as my go-to pharmacologic agents. Once we break through on top of that, I'd lean on an ablative strategy to help titrate meds to a manageable dose (fatigue for BB and QTc for sotalol with doses up to 120-160! bid on nadolol and 240 bid on sotalol).
On a related side note, not all beta-blockers are created equally and there are preferences based on what you're treating/what's been best studied; this tends to be my scheme/use:
- VT = nadolol and propranolol (references above)
- HF (reduced ejection fraction) = per 2022 ACC AHA HF guidelines carvedilol, metoprolol succinate, bisoprolol. I really just use carvedilol for higher BP, long-acting metoprolol for softer BP
- Aortopathy = no better-studied agent than atenolol
- Hypertension = I like the dual agents, BB with vasodilatory afterload reduction (labetalol and carvedilol via alpha-blockade, nebivolol via nitric oxide potentiating mechanism/B3)
- Atrial arrhythmia/rate control = metoprolol vs esmolol for short-acting drip